It is estimated that 88,000 people died of complications surrounding nosocomial infections in the US each year. By comparison, about 7,000 die each year in the US from medication errors. (2005 data)

There are numerous opportunities to spread infection in the healthcare environment. This topic alone can fill volumes. This post will focus on what an architect should know about the flow of sterile instruments in the surgical setting.

Know your flow.

Understand the route a surgical instrument will take in your department. It is different than that of the patient or staff. Start in the operating room.

1. Sterile instruments are placed into the room by staff for use in the next procedure.

2. After a procedure is completed, instruments are taken out of the room for cleaning. This room may be called clean-up, decontam, soiled utility, or simply “dirty”.

3. The instruments are cleaned of visible debris, deemed “clean” and moved to an assembly area.

4. In the assembly area, they are placed into a tray (also called a cassette) and typically enclosed in a sterile wrap. (It looks like a gift wrapped package in a blue paper towel. But, no bow.)

5. The wrapped instruments are then placed into a sterilizer where they are exposed to a process that will kill any microscopic organisms still alive. Steam, hydrogen peroxide and Ethylene Oxide are the most common.

6. The wrapped tray containing the sterile instruments is stored for use in the next procedure.

It is critical to understand the flow of patients, staff and instruments within the surgical setting. The progression from dirty to clean to sterile should be easily identifiable as you review the space. There are plenty of books dedicated to this topic. Take a weekend to become familiar and a month or so to become an expert.

Remember that almost 90,000 people die each year from infections introduced to them in the healthcare environment. Don’t expect this 5 minute read to place you in a position to solve the problem. Do your research and learn how you can make patients safer as a result of better design.

Start by becoming familiar with the tools of the trade:

Yes.  For once there is a trend in the imaging area that is making the room easier and cheaper to build. Finally! After 20 years of more and more sophisticated requirements, the newest general rad systems are a relative breeze to install. No ceiling infrastructure and no floor trenches.

Let’s compare:

(Click on an image to view details and then click your browsers back button to return.)

The newer units in the bottom row are all floor standing with a wall attachment for support. Electrical and cables are fed from the wall to the control area. The table is a simple gurney, with no electrical requirements at all. (Except the last image, which is attached to the arm.) The x-ray tube and detector are integral to the system, so no wall bucky either. Sounds simple doesn’t it?

Don’t forget about the basics. You still need a physicist report and room shielding. You still want an X-ray in-use sign for the entry door that is interfaced to the x-ray control. Last, there is a sort of “docking device” to lift the arm that holds the tube and detector. You will need a room to store this when it is time to service it. But you can stash it in the basement with the bio-med folks.

The change is driven by a number of factors. Financial, technological and market-driven. But, it seems safe to assume that the trend will not reverse itself. So before you get too far along in your design, set an appointment with the Imaging Director and have a discussion about the future. It just might save your project tens of thousands of dollars in design and infrastructure costs.

There is a rumor going around that Doctors – specifically surgeons – are notoriously impatient. I’m still gathering evidence to form my own opinion. But the idea of waiting for hot water before they scrub into a case can easily be seen as something that might be irritating. On a recent project, this was the scenario:

• Scrub sinks. These scrub sinks used were hands free infrared units with an internal timer.
• The faucets selected by the plumber were low-flow, to save water and prevent “splashing”. (Yes, these were CFCI vitreous china sinks with plumbing fixtures, not the all-in-one stainless steel units.)
• The hot water supply line is on a recirculating pump to the farthest point, but the scrub sinks are on individual feeds off of this main supply about 20 feet away.

Here is the process we found: The surgeon arrives to scrub into the case. He activates the sink and gets cold water. The internal timer times out and the surgeon must re-activate the flow of water. This time the water is just starting to get warm. On the third try, the water is hot and so is the surgeons mood. At the adjacent scrub sink alcove , this process repeats itself.

Lesson Learned:

Placing all of the scrub sinks on the same recirculating loop will help keep the hot water flowing instantly. This way, running the water in scrub sink location #1 is moving the hot water in the same pipes as scrub sink locations 2, 3, etc. This will save on the wasted water going down the drain from the first few attempts at warm water and give the docs one less thing to complain about. Other solutions might be placing insta-hot units at each sink location.

My Opinion:

On this topic of conversation, a better solution is the knee operated sink. It still keeps the controls off the floor so clean-up is easy and has less chance of breakdown. The infrared units are notoriously finicky and timers can be outfitted on the knee operated units easily.

Unimpressed the MRI tech invited me into the room. Damn that place was cold!

As it turns out, the signal from the thermostat in the room was being disturbed by either the magnetic field or the RF signal generated by the MRI. After some discussions with the MRI vendor, it turns out t-stats are not a good idea in the MRI room for the very reasons we were encountering. Signal interruption.

Instead, we simply placed a temperature probe into the return air duct outside of the room and connected it to the heat pump controlling the space. This method gives a very accurate indication of the room temperature and prevents any interference between the MRI and thermostat.

Lesson Learned: Rather than place a thermostat in the MRI room, simply place a temperature probe in the return air duct outside of the room. This places the temperature monitoring outside the shielding of the MRI room, avoiding the need to run the wires though a wave guide (AKA RF filter).

Let’s start by defining the components for entering data into the patient chart:

• Software
• Computer
• Charting surface. (Desk, cart, bracket or docking station)
• Scanners
• Training
• Typing Skills
• Device Integration
  

The EHR/EMR software is the brains of the system. It provides the user interface that a clinician enters the data into. The more intuitive, the easier to enter and the faster the charting process happens.

The computer is the vehicle for entry. It can be a PDA, tablet, notebook, laptop or PC. The smaller it is, the more portable. The larger it is, the more options for viewing and entry.

The charting surface is an integral part of the system and an important consideration for the architect. What are the requirements for your input device? Will is sit on a counter? Roll-in on a cart? Be carried by the caregiver? Or mounted to a bracket?

Scanning is a necessary evil when it comes to historical records. When a patient with an inch thick chart arrives at a facility with electronic charting, there is simply not enough manpower or cost-incentive to re-enter all of that data. It simply gets scanned and attached as a PDF. Make sure you allocate a location for record scanning. A facility may send out all of their existing charts to be scanned during the initial EHR implementation, but new patients are more than likely going to arrive with paper charts.

Training is an important area of consideration. Unlike accounting systems or other IT system that only a few staff members need to learn, the EHR needs every doctor, nurse, tech and social worker to possess some level of proficiency. Training costs are high because you are working with the highest paid staff.

Typing skills. Don’t confuse software training with typing skills. Doctors have notoriously poor handwriting, so why should their typing skills be any better? This is where an intuitive software interface that relies heavily on pre-set options is key. Requiring too much typing will likely lead to abbreviated charting. And by abbreviated I don’t mean using abbreviations. I mean docs who will say: “I’m just not going to write down every little detail because I have too many other patients waiting to see me and I refuse to sit here doing the “hunt and peck” while my patient stares at me like I should have taken a typing class rather than Anatomy 101.”

Device integration. This is where the most potential exists and the least progress has been made. Every patient care device with a CPU has the potential to export data directly into the patient record. A patient scale can export the weight. A vital signs monitor can export the blood pressure, heart rate, respiration and O2 saturation. A digital x-ray unit can export the image file. An EKG can export a report. This ability to extract patient data and moving it into the correct patient record with minimal effort is the “holy grail” of patient charting.

Key factors for designing an EMR/EHR friendly facility:

1) Determine the input device to be used.

2) Select a suitable platform to allow the caregiver to use the input device.

3) Investigate the other devices with direct input capabilities.

4) Provide the infrastructure to allow for input to occur. (RS232, RJ45, USB, Wireless, etc.)

If there is an area with the greatest potential for improvement, it is allowing multiple devices to interface directly to an EHR/EMR and by-pass manual entry by the caregiver.  This will reduce errors, increase the amount of data entered and offer far greater opportunities for data normalization and data mining.